Texting trial didn't get better antenatal care attendance, experiment found

Samoan women are not more likely to attend antenatal care classes by only being reminded of them via text, a study has found.

Results published from an experimental study conducted in 2014 reveal a text messaging system with antenatal tips and appointment reminders resulted in 15 per cent less attendance than from women who did not receive the texts.

The study trialled the texting system on 552 women from three clinics (76 per cent of those offered the service accepted it) and monitored an additional 225 women from three more clinics who were not texted between March and September 2014.

Lead researcher Dr. Jessica Watterson, a Public Health researcher from the University of California, said between women being very late into their pregnancies when they registered for the messages, not understanding the project and not always having their phone on them, the intervention was not a success.

“Unidirectional test messages do not encourage, and might even discourage A.N.C. (antenatal care) attendance in Samoa,” she wrote.

Local gynaecologist and general practitioner Dr. Salote Vaai said the lack of antenatal care in Samoa results in higher rates of infant and maternal mortality than there ought to be.

Many women’s first visit to the hospital while pregnant is in fact to give birth, she added, a situation that results in high rates of babies found in the breach position too late to be safely dealt with, or in the worst cases, high rates of stillborn births.

“Women here will turn up in labour and ready to push and deliver the baby and then we realise the baby is in breach. That is associated with more risks, morbidity and mortality for the babies,” Dr. Vaai said.

“Those are women who come into deliver and we are unable to find a heartbeat and a scan confirms the baby has already died.

“We’ll find out maybe the mother was hypertensive during pregnancy, but never knew or was diabetic and didn’t know, or that she was way past her due date, and this all could have been avoided with antenatal care.”

In Samoa, the infant mortality rate – the number of babies that do not survive childbirth – is 13.6 to every 1000 live births (as of 2018).

That is low for Samoa’s history (in 2006 it was 20.4, and in 2011 it was 15.6) but compared to other countries it is concerning, Dr. Vaai said.

In New Zealand, the figure for 2018 was just 3.8.

“To gauge the overall health of a country you look at infant and maternal mortality rates,” the doctor continued.

“We could be doing really well as a country but if our infant mortality rate isn’t dropping significantly every year we know we still have a long way to go.”

Dr. Watterson’s study was conducted at the District Hospitals or Health Centres in Faleolo, Leulumoega, Apia, Lufilufi, Lalomanu and Poutasi.

During the study, women received two educational messages about the stage in their pregnancy or tips on healthy eating, and were texted a reminder of their antenatal appointments the day before.

They were also reminded if they missed an appointment by four weeks.

While earlier research conducted in other countries showed text messaging systems improved attendance, results from Samoa showed the opposite.

Women receiving alert texts attended 15 per cent less sessions that those who did not.

“One potential explanation for this finding could be that the messages led participants to feel more connected to the clinic, or that they had sufficient information, reducing their motivation to attend an in-person check-up (ie, there was a substitution effect, whereby patients substituted information received by text message for more time-intensive ANC),” the researchers suggested.

The researchers also suspected younger women would be more receptive to the messaging, but they were not.

“A key barrier was difficulty with consistently offering and explaining interventions to women at intervention clinics,” the researchers state.

“Despite the implementing midwives participating in training at the program’s start and regular visits from the researcher to discuss the program and collect data, evidence suggests that some pregnant women might not have received a clear explanation of the program, or might not have been offered the program even if they registered for A.N.C. at an intervention clinic.”

They found the women often did not see the texts, or would respond to the messages asking what they were and who sent them, suggesting that the women were sharing their phones with others.

The local midwives involved in the study suggested the intervention would work better if husbands or partners were involved. The researchers did not seek feedback from the participating women.

Dr. Vaai said she has had successful return rates for antenatal care attendance by calling her patients or using Facebook Messenger, which is less “avoidable” than texting because it shows when a recipient opened a message.

But she admits the pregnant women who come to her private clinic, Health in Her Hands, are more likely to take their antenatal care needs seriously as they are paying higher rates for the clinic.

Those who can’t afford private practice have to attend the hospital, and many women will avoid that because of the waiting times that often won’t result in being seen at all.

Where once two or three doctors would attend to 30 patients during a three hour window, today patient numbers have doubled but the resources remain unchanged.

“This year I hear the antenatal clinic can go up to 60 [people] and it’s still only two or three doctors who struggle to get through all the patients in the three hours,” Dr. Vaai said.

“A woman can turn up at 9 and not be seen until 11:30, 12, after 12. If you imagine that one of these women comes from far away and they have to leave early in the morning and wait for hours, it’s a whole day trip for them basically.

“That is not, on paper, adequate antenatal care.”

According to the research, just 12 per cent of pregnant women register for antenatal care in their first trimester.

The World Health Organisation has set a target for at least four antenatal sessions during pregnancy. They are sessions that can help identify chronic conditions that will affect the child and mother in birth, like anaemia, hypertension or other disorders.

Dr. Vaai said the pre 1990’s model where healthcare was decentralised and distributed across the country among district hospitals and Komiti Tumama (women’s health committees) could hold one answer to improving access to, and uptake of antenatal care.

Instead, the centralised model where all services are primarily offered at the National Hospital in Moto’otua has seen too many families write off healthcare because it is too expensive or inconvenient to get to.

“The Government has tried, and we are seeing the system is overloaded and not working so perhaps one of the answers is to go back to utilising women’s committees.”

Diego Castaneda from Design for Health and Caricia Catalani of Facebook Research (both from California) also authored the study.  

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